A prospective randomised control trial to study the role of intra-peritoneal instillation of ropivacaine versus normal saline irrigation in reduction of post-operative pain in patients undergoing laparoscopic cholecystectomy.

The study was done to compare the effect of intra-peritoneal instillation of ropivacaine versus normal saline irrigation on post operative abdominal pain and shoulder pain in laparoscopic cholecystectomy. Ninety patients with symptomatic gall stones disease undergoing laparoscopic cholecystectomy were randomized in three groups. In study group A (n=30 patients) 0.5% of 30 ml (150 mg) of ropivacaine was instilled at gall bladder bed, and in study group B (n=30) 0.9% of 25 – 30 ml/kg of normal saline irrigation was done at gall bladder bed and sub-diaphragmatic space or control group C (n=30) none of above two intervention was done. Pain abdomen is worse during first 24 hours after laparoscopic cholecystectomy. At 6 hours pain abdomen was significantly less in group A compared to group B (p<.035). At 12 hours pain abdomen was less in group A and group B compared to control group. Intensity of shoulder tip pain was almost similar in group A and group B. Group A experienced significantly reduced shoulder tip pain at 6hours and 12 hours as compared to group C. Group B experienced less shoulder tip pain during first postoperative day as compared to control group. Intra-peritoneal instillation of ropivacaine is more effective than normal saline irrigation at early post-operative hours in reducing post-operative pain abdomen after laparoscopic cholecystectomy. However, intra-peritoneal instillation of ropivacaine and normal saline irrigation are comparable in its effect on shoulder tip pain

The study of laparoscopic cholecystectomy and its conversion to open cholecystectomy: analysis of 100 cases in Navi Mumbai, India

Background:  Laparoscopic cholecystectomy has now become a better option instead of open cholecystectomy for the treatment of cholelithiasis that is it has become a gold standard for cholelithiasis condition. Last century has been the most fruitful era for the treatment of biliary tract disease as it saw the progress from open to laparoscopic surgery with single port surgery etc.Methods: The purpose of our study is grading of Laparoscopic cholecystectomy and studying the outcome of problematic and challenging Laparoscopic cholecystectomy cases, its complication and management, to decide when to convert Laparoscopic cholecystectomy to open cholecystectomy. This study analyzes the conversion rate of laparoscopic cholecystectomy to open cholecystectomy in Navi Mumbai, India. This is a retrospective study of 100 patients conducted from October 2012 to October 2014.Results: Out of the 100 cases 98 got successfully operated by Laparoscopic cholecystectomy. Only 2 cases out of 100 got converted from Laparoscopic to open cholecystectomy and they belonged to grade E with empyema.Conclusions: Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic gall bladder. Laparoscopic cholecystectomy intra operatively for grade A to E where Grade A is very easy level of performing Gall bladder surgery to Grade E where conversion is 100% due to bad.

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones. Results of a retrospective; single center study between 1996-2002

AIM: The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients undergoing preoperative ERCP (= 8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCP. RESULTS: Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%, for three 72.5%, for four or more 91.4%. CONCLUSION: Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients). Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g. skill of the endoscopist, other diagnostic tools)

An evidence based guide to a safe intraoperative approach of avoiding iatrogenic lesions during difficult laparoscopic cholecystectomies

Introduction: Although there are many sources for iatrogenic lesions during laparoscopic cholecystectomy, only a few stand out as being one of the most difficult to predict due to their nature of being very hard to diagnose before surgery. Materials and Methods: a short guide of cases with an evidence-based approach to avoid laparoscopic iatrogenic lesions. Results: these cases have been classified and presented into 3 main groups: cases with abnormal arterial layout, cases with heavy alteration of the normal anatomy, and cases with anomalies of the main biliary pathway. Conclusions: while not a complete guide covering all aspects of intraoperative traps during laparoscopic cholecystectomy, this series of cases points out some dangerous situations and some simple solutions to avoid those fiercely iatrogenic lesions of the ductal and vascular landmarks associated with an otherwise simple surgical intervention that has become the golden standard of the gallbladder lithiasic pathology

Hemobilia due to cystic artery pseudoaneurysm: A rare late complication of laparoscopic cholecystectomy

We discuss a patient with late presentation of hemobilia following cholecystectomy, which is unusual because pseudoaneurysm caused by vascular injury during surgery typically presents soon after surgery. Endoscopic retrograde cholangiopancreatography revealed a large blood clot arising from the biliary orifice with subsequent computed tomography angiography diagnosing a large pseudoaneurysm in the region of the cystic artery adjacent to the cholecystectomy clips. Embolization was performed via direct percutaneous puncture of the pseudoaneurysm

Length of Stay for Laparoscopic Cholecystectomy

Background: Hospitals seek to maximize efficiency in stabilizing and discharging post-operative patients. The post-operative length of stay (LOS) for laparoscopic cholecystectomy surgeries in the short stay unit of a community hospital in the Portland area varies significantly with an average LOS of 170 minutes. Purpose: The purpose of this study was to isolate factors associated with decreased post-operative LOS for laparoscopic cholecystectomy surgeries to identify procedural changes that would help meet the goal of an average 120 minutes LOS. Methods: EPIC charts of 41 patients who received a laparoscopic cholecystectomy since July 1st 2014 were reviewed for data on specific factors of perioperative care. A literature review was also conducted to gather information on evidence based standards of care. Results: Data showed no differences in post-operative LOS for laparoscopic cholecystectomy patients based on gender, use of a nerve block, or pre-operative Xanax administration. Patients with the shortest LOS, under 120 minutes, received an average of three different antiemetics. Evidence based literature recommends using a combination of antiemetics during surgery to prevent post-operative nausea and vomiting (PONV). Discussion/Recommendation: PONV is a leading factor contributing to increased length of stay. The results of this study, along with evidence-based literature, suggests that a combination of at least three antiemetics during surgery can decrease PONV and thus decrease post-operative LOS for laparoscopic cholecystectomies

Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries

BACKGROUND: Complete reports of biliary and vascular injuries after laparoscopic cholecystectomy are rare. STUDY DESIGN: Fifteen patients with complex laparoscopic cholecystectomy injuries underwent corrective operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. Five of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein occlusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobectomy. Corrective biliary operations consisted of common hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepaticojejunostomy (one case), right posterior hepaticojejunostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases). RESULTS: Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations. CONCLUSIONS: A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecystectomy